Does Less Equal More in Late-Life Care?

Medicare paid too much for her dad's cure, and not enough for his care

To those who just finished wrangling with Medicare’s various parts during open enrollment, apologies. Now consider “Part Q,” for quality of life.

Journalist Katy Butler’s proposal of a not-yet-real Part Q appeared in this week’s New York Times Opinionator blogs. She wrote that her father’s long decline included more than $80,000 of Medicare-covered surgery, drugs and reactive fixes for the acute problems he developed. Medicare, however, paid far less for the few home-based services he finally got near the end of his life.

An outpatient team of a nurse, social worker and occupational therapist focused on preventive and supportive care. They remedied the day-to-day sources of her parents’ troubles: fall prevention for her father, respite for Butler’s caregiver mother.

The VA's home-based care program reduced hospitalizations by 25 percent, saved the VA and Medicare 10 to 12 percent and got high ratings.

Why Her Dad Suffered

“My father, and others like him, suffered because, at the tail end of life, Medicare continues to pay well for fix-it treatments focused unrealistically on cure and underpays for care and desperately needed home support,” Butler wrote.

How much better might her parents’ last few years have been if practical, home-based help had come sooner?, Butler asks. And how much might Medicare save if it paid the relatively low cost of more preventive and primary care and helped the frail elderly avoid acute health problems?

Part of the second answer is found in a Veteran’s Administration (VA) Home-Based Primary Care program. An analysis last year found that it reduced hospitalizations by 25 percent, saved the VA and Medicare 10 to 12 percent, and got high patient satisfaction ratings.

Time for Medicare Part Q?

Butler’s Part Q proposal would go further, gaining more savings for Medicare and better quality of life — and death. To personally qualify and enroll in an optional Medicare Part Q providing the better home-based care she wants, Butler said, “I would promise, upfront, to forgo medical treatments that evidence shows are outrageously expensive, not cost-effective, painful to endure, and likely to extend my life, if at all, by only months.”

How many of us, like Butler, are willing to make that trade? “Yes, I might die too soon rather than too late,” she wrote. “But I’d have a better shot at . . . ‘the Niagara Falls trajectory’: maintaining a high quality of life for as long as possible, followed by a mercifully rapid decline.”